the connection between UTI's and AD decline

[norbert1]

Added to misc dementia topics pt 2

What's the connection between UTI's and AD decline?

Q - I see all over the message board when a patient has a downward turn or "episode" of any kind, many many people refer to UTI's as being a possible underlying cause. What is the connection? And why don't we see this kind of connection being made with the common cold or the flu which seems to be a more frequent occurrence.

A - The elderly in general and especially those with dementia (because of lowered level of cognitive reserve) are susceptible to delirium. In dementia, UTIs cause a mild form of delirium that produces a decline in function and increase in confusion.

de•lir•i•um. A temporary state of mental confusion and fluctuating consciousness resulting from high fever, intoxication, shock, or other causes. It is characterized by anxiety, disorientation, hallucinations, delusions, and incoherent speech.

Google - dementia UTI delirium

Inflammatory Response To Infection And Injury May Worsen Dementia
www.medicalnewstoday.com/articles/121816.php
Systemic inflammation - inflammation in the body as a whole - is already known to have direct effects on brain function. Episodes of delirium, in which elderly and demented patients become extremely disoriented and confused, are frequently caused by infections, injury or surgery in these patients. For example, urinary tract infections, which are typically bacterial, appear to be particularly potent inducers of psychiatric symptoms.


Double trouble: When delirium complicates dementia
www.nursingcenter.com/prodev/ce_article.asp?tid=812348

Dementia Versus Delirium
www.selfhelpmagazine.com/article/dementia-delirium
“Delirium can be caused by virtually any medical condition. A urinary tract infection, reaction to drugs, low blood pressure, dehydration, even sensory deprivation for hospitalized patient.”

A comment on one line in this article. -- “Delirium is a true medical emergency.” -- The level of delirium caused by a UTI is not as severe as when caused by a more major illness and would not rise to the level of a “medical emergency”, but would produce a change of behavior. . . . However, a bladder infection can move up to the kidneys, where it can get into the blood stream creating sepsis. That IS a life threatening medical emergency.

Look at it another way, anything that produces stress on the body of a person with dementia will cause an increase in confusion and possible behavior issues. UTI, pain, dehydration or exhaustion will produce such results.

The complicating issue in dementia is that we can tell when they have a fever (from flu) or a cold, but they cannot or do not tell the caregiver that they have a UTI. And in dementia, they can have a silent UTI which does not exhibit the traditional symptoms.

Treating UTIs

Silent UTIs usually don't have any symptoms; no pain, burning, frequency or odor, but they are there. The only symptoms for many of our loved ones are abrupt changes in behavior, cognition or funcition.

One caregiver reported, in later stages, "my mother got these silent UTIs about five or so times a year. Her only symptom was that abrupt change in behavior or cognition. Once treated with the appropriate antibiotic, she was back to her usual level of function."

The facility is the one that should test the urine. A dipstick will be done first to check for bacteria. You can also test at home. The AZO test strip has two windows and is most accurate if the urine is held for 12 hours. Even if not held for 12 hours, the first window will still work properly to test for infection. If a UTI is present, then a lab culture will be done to check for the most effective antibiotic. The laboratory culture takes about three days to come back.

In the meantime, the MD usually treats the patient empirically with a broad spectrum antibiotic. If that antibiotic turns out not to be effective by culture, the antibiotic will be changed.

[MaryKathryn]

Thanks Norbert for the informative information of this post.

However, I tried clicking on to the high-lighted websites but a

message comes on that the "website cannot be found."


Never the less you have given us a whole lot of information on

this thread already. Many thanks,


Always grateful to you for any/all information you share with us,

MK

[norbert1]

MK, I am not sure what happened. Somehow the web addresses got shortened when I copied here. Here is the first article. I am still trying to access the second (not currently available)

www.medicalnewstoday.com/articles/121816.php
Inflammatory Response To Infection And Injury May Worsen Dementia
18 Sep 2008
Inflammation in the brain resulting from infection or injury may accelerate the progress of dementia, research funded by the Wellcome Trust suggests. The findings, published this week in the journal Biological Psychiatry, may have implications for the treatment and care of those living with dementia.

Systemic inflammation - inflammation in the body as a whole - is already known to have direct effects on brain function. Episodes of delirium, in which elderly and demented patients become extremely disoriented and confused, are frequently caused by infections, injury or surgery in these patients. For example, urinary tract infections, which are typically bacterial, appear to be particularly potent inducers of psychiatric symptoms.
Until now, there had been little research into the impact of systemic inflammation on the progress of dementia and neurodegenerative diseases. However, with over 700,000 people currently living in the UK with dementia - a figure set to rise with our ageing population - scientists are keen to understand more about the mechanisms behind such diseases.

Now, in a study to mimic the effect of bacterial infection in people with dementia, Dr Colm Cunningham and colleagues at Trinity College Dublin, in collaboration with Professor Hugh Perry at the University of Southampton have shown that the inflammatory response to infection in mice with prior neurodegenerative disease leads to exaggerated symptoms of the infection, causes changes in memory and learning and leads to accelerated progression of dementia.

"Our study clearly shows the damaging effect of systemic infection or inflammation in animal models of dementia," says Dr Cunningham, a Wellcome Trust Research Career Development Fellow.

In previous studies, Dr Cunningham and colleagues showed that infection-induced inflammation can exacerbate nerve cell damage in animal models of dementia. Now, the team has shown that just one episode of systemic inflammation could be sufficient to trigger a more rapid decline in neurological function.

"Doctors and carers need to pay increased attention to protect people with dementia from potential causes of systemic inflammation," says Dr Cunningham. "These include preventing infection, protecting them against falls and carefully weighing up the risk-benefit ratio of non-essential surgery."

Dr Cunningham believes the research may provide clues for helping slow down the progression of neurodegenerative diseases in humans. Although long-term use of non-steroidal anti-inflammatory drugs to treat conditions such as rheumatoid arthritis offers modest protection against the development of Alzheimer's disease, actually treating Alzheimer's patients with these drugs has not had a significant impact on disease progression.

The researchers found that systemic inflammation leads to the production of a protein known as IL-1â by microglia, the brain's resident immune cells, in the hippocampus region of the brain. This region is involved in memory and learning. The protein is known to exacerbate nerve cell damage in stroke. Inflammatory mediators such as IL-1â are routinely produced in the blood in response to inflammatory stimuli and prior studies by colleagues in Southampton have shown a correlation between elevated blood IL-1â levels, recent infection and subsequent cognitive decline.

"The recognition that relatively banal systemic inflammatory events can interact with and exacerbate neurodegenerative processes in the brain opens up potential avenues of treatment for patients with dementia," he says.

Rebecca Wood, Chief Executive of the Alzheimer's Research Trust, commented:

"This is really interesting research leading to a significant step forward in our understanding of dementia. Inflammation has been implicated in dementia for some time, which is why falls are of such concern, but this also shows that the dementia is increased by another common problem of ageing - urinary tract and other infections. It also demonstrates how important it is to lower our dementia risk through maintaining good overall health.

"In the UK, 25 million of us know a close friend or family member with dementia, but research into the condition is severely underfunded. We need far more research like this if we are to reduce dementia's impact on our society."

[norbert1]

www.selfhelpmagazine.com/article/dementia-delirium
Dementia Versus Delirium
By Emily Carton, LISW

Many times in my geriatric practice a child or neighbor will notice that an older person is very forgetful, confused, and disoriented. There is often an assumption that it is just a sign of a dementia such as Alzheimer's and that there is little that can be done. This is not necessarily so.

If one is attuned to the differences between a dementia, which is long term and slow progressing, and a delirium, which has a quick onset and can be caused by other medical problems, often the symptoms can be reversed or prevented from creating further medical and mental damage.

More than once in my practice I have been called upon when an older person suddenly is confused, feeling ill, and has a sudden personality change. For several of my fortunate clients, it turned out that a urinary tract infection was the cause of these symptoms or a medication had been causing severe side effects.

The key factor is acting quickly and finding the source of the sudden change of mental status. Even if the older person is unaware of the change, is belligerent about seeing a doctor, trust your intuition if you feel that something is not right. Sudden changes can indicate a medical emergency.

Dementia: What is it??
Dementia is an acquired loss of intellectual functioning. It occurs over a long period of time. There are many causes of dementia including Alzheimer's disease, strokes, long-term alcohol abuse, and a reaction to medication, Vitamin B12 deficiency, thyroid disease and depression.
Symptoms and duration of dementia can be months to years. Usually speech remains normal. Generally attention is normal, although the person usually shows signs of difficulty in finding the right words. Recent memory is impaired. The older person's motor abilities remain normal until late in the disease. The individual's mood may be apathetic and there can be a loss of impulse control.

Delirium: How is It Different from Dementia?
Delirium is often caused by a sudden change in mental functioning and/or acute confusion. Emphasis needs to be placed on the word sudden. This condition can be extremely serious and require immediate medical attention to prevent any permanent damage.

Some of the hallmark signs of delirium are: a quick onset of symptoms, disorganized thinking, disorientation to time and place, reduced level of attention, drowsiness, increased or decreased psychomotor activity: either apathy which can sometimes be mistaken for depression, or increased agitation. Disturbances in sleep cycle are also a sign.

Delirium can be caused by virtually any medical condition. A urinary tract infection, reaction to drugs, low blood pressure, dehydration, even sensory deprivation for hospitalized patient or with hearing or other impairments that keep them isolated, and alcohol withdrawal are just a few of the many possibilities that can cause this disorder.

Delirium is a true medical emergency. (My note, The delirium caused by UTI only is not a medical emergency requiring hospitalization. However, consult the doctor for treatment.) Immediate evaluation and treatment needs to be obtained. The specific cause of the delirium needs to be found, so the person can be treated.

Approximately 25 percent of people over the age of 70 who are admitted to a medical hospital have delirium. Those suffering with dementia have a higher risk of developing delirium as well.
Differentiating between dementia, delirium and even depression, which can cause some of the same symptoms can be confusing. It is important not to take any of the symptoms for granted. Seek medical advice as soon as you notice a sudden change in a person's functioning. It can make an enormous difference in the outcome for the future.

About the Author:
Emily Carton, LISW is a licensed social worker who works with Elder Options, a private care social service firm in the DC Metropolitan Area. She is also an intern in Bibliotherapy at St. Elizabeth's Hospital in Washington D.C.
Originally published 5/13/98
Revised 9/02/08 by Marlene M. Maheu, Ph.D.

[norbert1]

www.nursingcenter.com/prodev/ce_article.asp?tid=812348
Double trouble: When delirium complicates dementia
Nursing2008
September 2008
Volume 38 Number 9
Pages 48 – 54
Denise L. Lyons GCNS, BC, MSN
Shannon M. Grimley CGP, PharmD
Linda Sydnor GCNS, BC, MSN
2 C.E. credits available for this article.

AN OLDER ADULT with dementia faces an increased risk of delirium if she experiences the stress of illness or hospitalization. Superimposed on dementia, delirium can lead to various serious and long-lasting complications, including a decline in her cognitive and physical function, increased length of stay, greater need for nursing care, delayed rehabilitation, and nursing home placement. It's also associated with higher readmission and mortality.1,2

Studies on the prevalence of delirium in people age 65 or older with dementia vary from 22% to 89%,3 but delirium superimposed on dementia may be underreported because it's often unrecognized or pigeonholed as worsening dementia. One literature review revealed that up to 25% of older adults are hospitalized with delirium and up to 56% develop delirium while hospitalized.4

Early recognition of delirium in a patient with dementia and treatment of the underlying cause can help prevent a poor outcome for your patient. In this article, we'll explain how to care for a patient with dementia who develops delirium and discuss what you can do to reduce risks. To illustrate, let's consider a hypothetical case study.

Behavior changes
Eugenia Baker, 88, is admitted to a medical unit from home with a diagnosis of acute change in mental status. Her medical history includes dementia, breast cancer, and ambulatory dysfunction. She lives with her daughter Carol and son-in-law Phil.
At admission, Carol tells you that Mrs. Baker is typically oriented to person and place. Although confused at times, she's generally cooperative. Her appetite over the past week has been poor. About 2 days ago, she became increasingly confused and agitated. Carol describes occasional episodes of hitting and biting and says her mother started seeing things that weren't there.

Once settled in her room, Mrs. Baker is alert but disoriented, agitated, and occasionally combative. When she agrees to let you assess her, she tells you she has pain in her abdomen and her rectum. You ask about Mrs. Baker's bowel routine. Carol isn't sure when her mother last had a bowel movement.

Mrs. Baker's admitting orders include a chest X-ray, ECG, complete blood cell count, basic metabolic panel, and vitamin B12, folate, thyroid-stimulating hormone levels, and urinalysis. When you inform the physician of her bowel history and abdominal pain, he also orders a plain X-ray of the abdomen. Because Mrs. Baker makes repeated attempts to climb out of bed, the nurses place her in a reclining chair next to the nurses' station so they can watch her closely.

Which is which?
Mrs. Baker's acute change in mental status may indicate delirium superimposed on dementia. Health care professionals have difficulty distinguishing the two,5 but the differences are very distinct. (See How delirium and dementia differ for more details.)

* Dementia is chronic. It develops gradually and usually isn't reversible. Early in the course of dementia, short-term memory deficits are common. Over months to years, the patient experiences a chronic, steady decline in cognition, use of language, and functional abilities.

* Delirium is an acute change in mental status, typically due to a reversible medical condition. Hallmarks include acute onset, a fluctuating course, change in cognition, and decreased attention. Treating the underlying cause usually reverses delirium.

Suspect delirium whenever a patient with dementia has an acute change in cognitive status, behavior, or physical functioning. As in Mrs. Baker's case, a family member might tell you she's noticed a big change in a short time.

Prevention is the best medicine
Even in a patient with dementia, delirium may be preventable or quickly reversed. Early recognition of an acute change in her mental status is critical, so frequently assess for red flags to improve the quality of care and reduce complications. Besides assessing mental status, manage your patient's environment and immediately respond to suspected physiologic causes of delirium—most commonly, medications, infection, respiratory tract disorders, and fluid or electrolyte imbalances. (See Common causes of D-E-L-I-R-I-U-M.)
If delirium develops, consider it a medical emergency and immediately investigate the cause.

Zeroing in on causes
Dementia impairs a patient's ability to communicate, so use various strategies and information sources to gain insight into her acute mental changes. These include observation of the patient's behavior, physical assessment, diagnostic study results, patient history from family members, and the medical record. Zero in on the following factors:6

* vital signs
* SpO2 level
* lung sounds
* pain level
* blood glucose level
* urinalysis
* bladder scan to assess for urine retention
* record of bowel movements
* digital rectal exam for fecal impaction
* fluid intake and output
* presence of medical devices, such as a venous access device or indwelling urinary catheter
* current or recent use of medications with psychoactive effects
* new medications or recent dosage changes to current

medications. (See Medications that can trigger trouble.)
Results of Mrs. Baker's urinalysis show white blood cells and nitrites, suggesting a urinary tract infection (UTI). The health care provider orders a urine culture and an I.V. antibiotic to be started after urine is obtained for culture.
The abdominal X-ray indicates a large amount of stool in Mrs. Baker's colon, so he also orders a digital rectal examination. Initial management of the fecal impaction includes disimpaction and oral polyethylene glycol solution (GoLytely). Additional interventions include stool softeners as appropriate, increasing mobility, scheduled toileting, and avoiding constipating drugs.7

Two diagnostic tools for delirium
Diagnosis of delirium is primarily clinical and must be based on careful bedside observation of key features. Two tools can help:

* Confusion Assessment Method (CAM). This standardized tool has a sensitivity rating of 94% to 100% and a specificity of 89% to 95%.8 It's available in long and short forms, as well as a version for nonverbal mechanically ventilated patients. Key features of the short form are acute onset or fluctuating course, inattention, disorganized thinking, and altered level of consciousness. Diagnosis of delirium by CAM requires the first two features plus at least one of the last two. These four features are considered to be best for distinguishing delirium from other types of cognitive impairment.

* NEECHAM Confusion Scale. Based on a structured database derived from routine nursing assessments and interactions with patients, this tool evaluates nine items divided into three subscales: level of responsiveness—information processing, level of behavior, and vital functions. It has the advantage of detecting early stages of delirium and is sensitive to its fluctuations.9
No matter which tool you may use, the earlier delirium is detected and the underlying problem treated, the better the patient's prognosis.

Mrs. Baker's history, clinical condition, and diagnostic test results suggest delirium superimposed on dementia probably caused by her UTI and fecal impaction, two common risk factors for delirium in older adults. Initiating treatment for these underlying causes are important first steps to reversing her delirium.

Pharmacologic management . . . .

Back to baseline
After 4 days of pharmacologic and nonpharmacologic measures to manage delirium and treat her infection and constipation, Mrs. Baker is alert, responsive, and cooperative. She's no longer hallucinating, her appetite is good, and her bowel movements are normal. She denies rectal pain, and her urinalysis is negative. By recognizing her delirium, investigating the causes, and responding appropriately, you've kept her safe and helped her return to baseline mental status at discharge.

Who's at risk?
Predictable risk factors for developing delirium include the following:
* age greater than 70
* history of dementia
* sleep deprivation
* hearing or visual impairment
* dehydration
* severe illness or fractures
* hospitalization
* recent surgery
* immobility
* previous episodes of delirium
* polypharmacy
* alcoholism
* multiple comorbidities.

Common causes of D-E-L-I-R-I-U-M

Drugs
* prescribed, over-the-counter, and recreational
* alcohol withdrawal or intoxication
* polypharmacy (more than four medications)
* effects of anticholinergic drugs, psychoactive drugs (anxiolytics, sedatives, hypnotics, antipsychotics, antidepressants), opioids, steroids
* drug toxicity, drug withdrawal
Elimination
* urinary retention
* fecal impaction or diarrhea
Liver and other organs
* liver failure, hepatitis, cirrhosis
* heart failure, myocardial infarction, hypotension, dysrhythmia
* kidney dialysis, renal insufficiency
* gastrointestinal bleeding, inflammation, infarction, infection
* stroke, cerebral edema, subdural hematoma, head injury, hydrocephalus, encephalopathy, meningitis
* bone marrow disease (anemia)
Infection
* urinary tract or respiratory infection
* sepsis
Respiratory
* hypoxia, pneumonia, pulmonary embolism, chronic obstructive pulmonary disease, asthma
* abnormal arterial blood gases, carbon dioxide, retention, hyperventilation
Injury
* trauma, pain
* stress
Unfamiliar environment
* restraint use, underlying dementia
* hospitalization or change in residence
Metabolic
* fluid/electrolyte disturbance
* dehydration/volume depletion
* abnormal blood glucose level
* elevated blood urea nitrogen or creatinine level
* vitamin B12/folate deficiency
* hypothyroidism, hyperthyroidism
* fever, hypothermia.
Adapted with permission from Christiana Care Health System Delirium Care Management Guideline.

Medications that can trigger trouble
Many drugs can cause or exacerbate delirium. Keep in mind that the following list of examples isn't inclusive and that any new medication added to the patient's regimen can also cause trouble.
* Alzheimer's medications
* Opioid analgesics
* Nonopioid analgesics
* All anesthetics
* Antianxiety/hypnotic agents, sedatives
* Antiseizure drugs
* Antidepressants
* Antihistamines
* Antihypertensives
* Antimicrobials
* Anti-Parkinson's medications
* Antispasmodics (urinary)
* Cardiac medications
* Glucocorticoids
* Muscle relaxants
Adapted with permission from Christiana Care Health System Delirium Care Management Guideline.

[larousse]

I didn't read through all of Norbert's posts above but I thought it useful to add:

A UTI may show up in change in color in the uring (darker) or cloudiness in the urine. Don't need tests in that case to know that a doctor visit is in order!

[andrea]

What is a UTI?

Thanks,

Andrea

[snowylynne9]

Urinary tract Infection.

[alice]

Bringing this to the top as there seems to be a lot of questions about UTI and AD. Very informative post Norbert..we miss you..alice

[ridzene]

bump up for minetta